1. Atherosclerotic Cardiovascular Heart Disease in Women
Millee Singh DO
Non Invasive Cardiology
First Coast Heart and Vascular

2. Overview
More than one in three female adults has some form of cardiovascular disease (CVD)
Since 1984, the number of CVD deaths for females has exceeded those for males
On average Females represented 51.0% of deaths from CVD
 In 2010, CVD was the first listed diagnosis of 2.8 million females discharged from short-stay hospitals
Most recent data show that 25.1% of bypass and 32.9% of PCI ,31.3% of heart transplant patients were female
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

3. CVD
Male
CVD
Female
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

4. Coronary Heart Disease In Women
 About 6.6 million females alive today have CHD
Of these, 2.6 million have a history of myocardial infarction (MI, or heart attack)
Each year new and recurrent MI and fatal CHD will impact an estimated 380,000 women
26% of women age 45 and older who have an initial recognized MI (heart attack) die within a year compared with 19% of men
 64% of women who died suddenly of CHD had no previous symptoms
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

5. Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

6. Angina Pectoris
 More women than men have angina in total numbers (4.1 million vs. 3.7 million)
 Angina among non-Hispanic women age 20 and older:
2.8% of non-Hispanic whites
5.4% of non-Hispanic blacks
3.3% of Mexican Americans
Each year about 180,000 women over age 45 are diagnosed with stable angina
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

7. CVD Stroke Lung CA Breast CA
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

8. Clinical Presentation
Women with CHD are generally about 10 years older than men at the time of presentation
Although women are generally older than men at presentation, women younger than age 45 years also develop CHD and have a worse prognosis than men
The first presentation of CHD may be chest pain, myocardial infarction (MI), heart failure (HF), or sudden cardiac death (SCD)
The Framingham Risk Estimation underestimates risk in women -the Reynolds Risk Score, have been developed specifically for use in women
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

9. SYMPTOMS: CHEST PAIN
While differences between women and men -there are more similarities than differences!
Chest pain is the most common anginal symptom in both sexes with regard to:
Quality of pain (heaviness, pressure)
Pattern of radiation
Associated symptoms
The quality of chest pain (typical versus atypical) is an important predictor of angiographic disease in women
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

10. Unrecognized/Asymptomatic MI
MI in women may go unrecognized, particularly at younger ages and when compared to men:
Icelandic study : 13,000 women were followed for 29 years
MI that went unrecognized was higher in the younger women (41 versus 24 %)
2003,a report In Circulation ; of 515 women with an acute MI, acute chest pain was absent in 43 % and only 30 % experienced prodromal chest pain
2012 , Jama ; study of over 1,000,000 women and men in the National Registry of Myocardial Infarction (United States)
the proportion of MI patients who presented without chest pain was significantly higher for women than men (42.0 versus 30.7 %)
McSweeney JC, Cody M, O'Sullivan P, et al. Women's early warning symptoms of acute myocardial infarction. Circulation 2003; 108:2619
Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA 2012; 307:813.

11. NSTEMI
Optimal approach to accurate assessment of risk in women with a non-ST elevation ACS may differ from that in men
TACTICS-TIMI 18:
Women were more likely to have elevations of hs-CRP, BNP, and less likely to have elevations of troponins and CKMB, than men, despite similar levels of risk
Women with any positive marker benefited from an invasive strategy
Women with no positive markers benefited from a conservative strategy
Men benefited from an invasive strategy when there was biomarker positivity and no differnence in benefit if they were negative
Women with unstable angina Without positive biomarkers should be treated conservatively, without early catheterization or use of glycoprotein IIb/IIIa inhibitors

12. SCD
Sudden cardiac death — A 38-year follow-up from the Framingham Heart study

13. Testing In Women Treadmill stress testing Nuclear stress testing
Stress echo
CT calcium score
Coronary CTA
Cardiac catheterization with coronary angiography

14. How good are the tests? Sen/Spec
ETT only (lower than in men)
61% and 70%
Stress Nuclear (similar in men)
78% and 64%
Stress Echo (similar in men)
86% and 79%

15. As for CCTA, Where does this stand?
ROMICAT trial
Women had greater reduction in LOS, lower admission rates, lower radiation doses
More normal studies, less obstructive dz
Lower radiation doses then a nuclear medicine scan
Focal radiation to the breast is present- no confirmed link to increased in Breast CA

16. Radiation Exposure for Women
Courtesy of Ana Barac, MD, ACC HWH 2014

17. Positive Test ? What next?
Women less likely to be referred for further evaluation if they have a positive stress test!
Higher incidence of MI or death in these patients have been noted

18. Cardiac Catheterization
Less likely to be referred
Higher complication rate than in men
Smaller arteries, more bleeding
But these pts do better than if no intervention
Higher peri-procedural rate of complication but better long-term survival than men

19. Preventative Measures
All Women
Exercise
Quit smoking
Healthy diet
BMI <25, waist circumference <35 in.
Treat risk factors: HTN, DM, dyslipidemia
ASA – look at risk/benefit ratio

20. DDX
Women’s ischemic heart disease (syndrome X, micro vascular disease)
Myocarditis
Stress-induced cardiomyopathy
Coronary dissection

21. Key Points CAD and CVD are by far the biggest health risks for women
Awareness is still less than it needs to be
Prevention CAN reduce risk
Screening programs are available
Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update;Myamericanheart.org

22. Key Points Women can present differently, and do worse when they do
Women are referred less often for appropriate testing and treatment
Women can have more complications from treatment, but still fare better than without treatment